Provider Demographics
NPI:1275841223
Name:G. FAZILAT, INC
Entity Type:Organization
Organization Name:G. FAZILAT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GOLAREH
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZILAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-502-3333
Mailing Address - Street 1:23832 ROCKFIELD BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2820
Mailing Address - Country:US
Mailing Address - Phone:949-502-3333
Mailing Address - Fax:949-229-3685
Practice Address - Street 1:23832 ROCKFIELD BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2820
Practice Address - Country:US
Practice Address - Phone:949-502-3333
Practice Address - Fax:949-229-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty